Provider Demographics
NPI:1013073766
Name:PHAN, DOUGLAS M (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:927 BROADWAY ST
Mailing Address - Street 2:SUITE 322
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:
Practice Address - Street 1:1541 FLORIDA AVE STE 304
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4439
Practice Address - Country:US
Practice Address - Phone:209-577-3388
Practice Address - Fax:209-521-3262
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG51181207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G511810Medicare PIN